Objective. To evaluate the perinatal outcome of expectant management of early onset, severe pre-eclampsia. Design. Prospective case series extending over a five-year period. Setting. Tertiary referral centre. Population. All women (n = 340) presenting with early onset, severe pre-eclampsia, where both mother and the fetus were otherwise stable. Methods. Frequent clinical and biochemical monitoring of maternal status with careful blood pressure control. Fetal surveillance included six-hourly heart rate monitoring, weekly Doppler and ultrasound evaluation of the fetus every two weeks. All examinations were carded out in a high care obstetric ward. Main outcome measures. Prolongation of gestation, perinatal mortality rate, neonatal survival and major complications. Results. A mean of 11 days were gained by expectant management. The perinatal mortality rate was 24/1000 (≥ 1000 g/7 days) with a neonatal survival rate of 94%. Multivariate analysis showed only gestational age at delivery to be significantly associated with neonatal outcome. Chief contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. Three pregnancies (0.8%) were terminated prior to viability and only two (0.5%) intrauterine deaths occurred, both due to placental abruption. Most women (81.5%) were delivered by caesarean section with fetal distress the most common reason for delivery. Neonatal intensive care was necessary in 40.7% of cases, with these babies staying a median of six days in intensive care. Conclusion. Expectant management of early onset, severe pre-eclampsia and careful neonatal care led to high perinatal and neonatal survival rates. It also allowed the judicious use of neonatal intensive care facilities. Neonatal sepsis remains a cause for concern.